Geriatric Health Care
Today, we had an opportunity to join the morning activity held for the elderly. So we began the day with 'Xiang Gong', a form of aerobic sequence practised by a group of elderly people who belong to the Geriatrics Club under the district. As soon as we reached there at 8am, the aerobic intructress, Mdm. Zakiah Ahmad introduced us to the lovely elderly ladies who came for the session today morning. We felt welcomed by their easy charm and friendly nature and thus, we joined them and did some of the exercise and later continued talking to them about common geriatric health care and facilities.
The geriatric club mentioned above is a non-governmental programme called Kelab Warga Emas, founded in the 1970s under the initiative of a kind doctor. All the district health offices in Kubang Pasu will have one club in each district, however it is maintained and monitored entirely by a group of elderly people under the DHO's guidance. They have about 100 members of which around 60 members are active in the club. The age requirement for membership is 60 and above and the fees is RM12 annually. Despite not receiving any financial allocations from the government, they are able to raise their own funds as most of them are ex-teachers and peple who have held significant posts in govermental sectors. Their activies include morning exercise sessions on Sundays, Tuesdays and Thursdays, religious classes to read Quran, parties, health promotion campaigns and talks among the elderly people in the surrounding area and vacation trips. They also own a building in the DHO in which they carry out their activities.
Our next talk was conducted by PPKP Amin B. Saad. He offered us information on the geriatric health care in Kubang Pasu District. In this district, there are a total of 17000 elderly people. There is no separate unit for geriatrics, instead there is a geriatric clinic for elderly patients where they will be followed up for early detection of health problems. Most of the activities carried out for the elderly are NGO based and therefore the government participation is minimal. However, despite the small scale involvement, the government has significant roles in providing the most efficient health care service for the elderly. As geriatric care is under the community welfare department, services like providing suitable housing plan for disabled elderly, home care and rehabilitative care are also available.
NON-COMMUNICABLE DISEASE
After a short break, the session was conducted by En. Kuswadinata (PPKP from Changlun) and En. Amin on non-communicable disease. En. Kuswadinata briefed us about diabetic clinic in Kubang Pasu district.
The main objective of this clinic is to reduce the mortality and morbidity due to diabetes. Here are the specific objectives:
- To provide efficient management on diabetes
- To create awareness about diabetes and its complications among the patients
- To improve patient's compliance in treatment, diet control and follow-up treatment
- To reduce the number of defaulter among the diabetic patients
- To provide a trained work force to control diabetes
is comprised of Family Medicine Specialist (FMS), Medical Officer (MO), Assistant Medical Officer (AMO), Staff Nurse, Assistant Nurse, Jururawat Masyarakat, Lab technician and Attendant. Role of FMS is to plan comprehensive services include long term goal for clinic, monitor services at clinic, handle all complex cases, conduct regular meetings with all members of clinic and monitor reports related to diabetes. Whereas MO will deal with cases referred by AMO, follow-up treatment for all diabetic patients on insulin therapy, examination of fundus and foot and also give counseling as well as health education to patients.
This diabetic clinic needs registration book, appointment book and direct fundoscopy/ fundus camera screening for diabetic retinopathy. The required equipments are monofilament, tuning fork, tendon hammer, ECG machine, weighing scale, Snellen chart, ophthalmoscope and so on.
(a) Fundoscopy is only available in KK Kepala Batas. The indicated patients from this district will be referred to that particular health clinic
(b) Monofilaments are constructed to buckle when a 10-g force is applied. Loss of the ability to detect this pressure at one or more anatomic sites on the plantar surface of the foot has been associated with loss of large-fiber nerve function.
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| Figure 1: Monofilament and the technique for testing pressure |
He briefed us on the
technique for testing pressure. Patients should close their eyes while being tested. The sensation of pressure using the monofilament should be first demonstrated to the patient on a proximal site (like upper arm). The sites of the foot then be examined by asking the patient to respond "yes" or "no" when asked whether the monofilament is being applied to the particular site. Areas of callus should always be avoided when testing for pressure perception.
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| Figure 2: Sites to be tested on each foot: 1st, 3rd, 5th metatarsal heads and plantar surface of diatal hallux |
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| Figure 3: 128-Hz Tuning Fork |
(c) The tuning fork provides an easy and inexpensive test of vibratory sensation. He showed us 128 Hz tuning fork and briefed us on its function. He added that vibratory sensation should be tested over the tip of the great toe bilaterally. An abnormal response can be defined as when the patient losses vibratory sensation and the examiner still preceives it while holding the fork on the tip of the toe.
Diabetes Registry Malaysia (DRM)
It is a mother registry for Diabetes mellitus. Adult diabetes registry known as An Adult of Diabetes Control and Management (ADCM) and Diabetes in children and Adolescents Registry (DiCARE) will come under one umbrella. So far, there is no case of DM Type 1 has reported in Kubang Pasu district. This registry is a MOH supported service to collect information about diabetes. According to him, the new cases will be entered in DRM and the follow-up cases should be recorded manually in Green Book. There are two copies of the green book which are exactly the same in contents, The larger one is kept as a record by the clinic and the smaller book is given to patient for their referral.
Total number of diabetic cases has reported in Kubang Pasu district in 2010 is 331 and the prevalence rate is 4131.
Monitoring the patient
In every visit, BP, weigt, urinalysis, symptomatic screening and drug compliance screening are done. If blood glucose level is normal, they will be attended by MA. All diabetic patients will be screened every year to detect complications and should start with early treatment. ECG should be done at least once a year. In addition to that fundoscopy and foot examination also be done once a year unless indicated. Screening for complications of legs include sensation, vibration, pin-prick, pulse and ankle reflex.
The indications for laboratory investigation are as following:
Urine microalbumin if urine protein (microalbumin) is negative
HbA1C is ideally should be done once every 3-4 months but here due to money constrain it will be performed every 6 months or at least once a year.
Liver function test (LFT) may performed if the patient is on statin or obese and done once a year at least.
Renal profile, Fasting Blood Glucose (FBG) is done a least once every 6 months.
Full blood count (FBC) is performed for renal impairment patient.
The defaulter tracing
It is done by phone if patient fail to attend the appointment within 2 weeks time. The patient will be inquired upon the reason and the next appointment date will be given. If still they fail to come for check-up, this unit will label that particular patient as defaulter. There is no other effort is taken on this issue due to money constrain.
Multidisciplinary DM Clinic
Ideally it consists of Nephrologist, Endocrinologist visit, Cardiologist, Ophthalmologist, OT/podiatrist, Physiotherapist, Dietician and Diabetes educators. The sad part is that this concept is not applied here. Only dietician and diabetes educators are available in this clinic so far. For the rest of disciplinary, the patients will be referred to hospital. Diabetic educators concerns on counseling on various aspects like screening for complications, initiation of insulin therapy and delivery system, foot care, SMBG (Self Monitoring Blood Glucose), help patient to achieve target, set goals and help patient to achieve them and facilitates the clinician in the management.
Self Monitoring Blood Glucose (SMBG)
It is recommended for people with diabetes in order to achieve a specific level of glycaemic control and to prevent hypoglycemia. The goal of SMBG is to collect detailed information about blood glucose at many time points to enable maintenance of a more constant glucose level by more precise regiments. The patients can get the SMBG machine in cheaper price by joining Malaysian Diabetes Association where the registration fee is only RM 5.
Medications used for diabetes
OHA : Metformin, Gliclazide, Glibenclamide, Glucovance
Insulin: Actrapid, Insulatard, Mixtard
Short fall in Quality (SIQ)
SIQ is an indicator for either of the two 6-monthly reporting periods. A quality improvement study is undertaken whereby an analysis of the reasons for the SIQ are determined. It will be labelled as SIQ when the percentage is less than 30 %. Then, investigation should be done to figure out the reasons and come up with future plan. According to this indicator, Kubang Pasu district has not reached the target. In this district, only KK Tunjang reaches the target.
No | CLINIC | SAMPLE SIZE | NO. OF PATIENTS WITH HbA1c < 6.5% | % OF PATIENTS WITH HbA1c < 6.5% | SIQ |
1 | Klinik Kesihatan Air Hitam | 102 | 21 | 20.6 | YES |
2 | Klinik Kesihatan Banai | 102 | 12 | 11.8 | YES |
3 | Klinik Kesihatan Changlun | 102 | 17 | 16.7 | YES |
4 | Klinik Kesihatan Kepala Batas | 102 | 16 | 15.7 | YES |
5 | Klinik Kesihatan Kodiang | 102 | 13 | 12.7 | YES |
6 | Klinik Kesihatan Laka Temin | 102 | 12 | 11.8 | YES |
7 | Klinik Kesihatan Tunjang | 102 | 35 | 34.3 | NO |
| TOTAL | 714 | 126 | 17.6 | |
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HbA1c < 6.5% in kubang Pasu district: | 17.6 % |
SIQ (<30%) for district : yes |
SMOKING
En. Amin took over the session and briefed us on topic of "smoking".
Quit Smoking Clinics
These clinics provided to assist smokes to quit smoking via techniques which are proven effective, such as through behavioural modifications and nicotine replacement therapy. The objectives are to provide knowledge and skills for smokers toquit smoking, to treat and rehabilitate smokers who intend to quit smoking, to provide awareness to smokers on the harmful effects of smoking and to encourage and motivate smokers not to return to smoke and maintain the non smoking status. It is available in Changloon, Tunjang, Kodiang, Air Hitam and KKB Jitra in this district.
Fagerstrom test
This test helps to determine the level of addiction to cigarettes. Write down the number of points identified by the answer for each question and total them. The questionnaire is attached below.
http://www.mytherapysession.com/PDFs/FagerstromNicotineDependenceTest.pdf
Carbon Monoxide (CO) Test
This test is cost effective CO monitor available here. There are 4 ranges of CO levels are featured on custom LCD.
- Green Light : Indicates non-smoker which ranges from 0-6 ppm
- Amber light : Indicates a light smoker which ranges from 7 to 10 ppm
- Red light : Indicates a smoker which ranges from 11 to 20 ppm
- Red flashing light with audible alarm : Indicates a heavy smoker which is above 20 ppm
Control of Tobacco Product Regulations 2004
- Part IV : Prohibition on smoking
- Regulation 11
- Sub-regulation 11 (1) - list of at least 19 smoke free locations
- Sub-regulation 11 (2) - Power of the Minister o Health to determine smoking area
- Sub-regulation 11 (3) - Penalty : Fine not exceeding RM 10, 000 or imprisonment not exceeding 2 years
- Regulation 12 - Duty of proprietor etc., of the premises or vehicle
- Regulation 21 - Provision for air-conditioned eating place, non-air conditioned public transport terminal or open air stadium
Champix
It is a Group C medicine indicated for smoking cessation in adults. It is available in two strengths : 0.5mg and 1.0 mg. The side-effects of this is symptoms associated with depression were suicidal adeation and suicide attempt. Currently, it is not used due to its side-effects. This warning is included in Malaysia's prescribing information leaflet under section "Special Warnings and Precautions for Use" and "Undesirable Effects".
Nicotine Replacement Therapy (NRT)
It consists of nicotine gum, nicotine patch and nicotine tablets are the main medications to aid smoking cessation here. Currently, this therapy is not provided in health clinic due to budget problem. Anyway, smokers can get it from pharmacy but it is expensive. "Where there's a will, there's a way". If one really want to quit, they can do it no matter what.
